Shame: Secret Ally of Illness

Last Editorial Review: 6/8/2005

Experts tell WebMD how shame can have an impact on health.

By Daniel DeNoon
WebMD Feature

Reviewed By Brunilda Nazario

Think positive. Eat good foods. Be healthy. It's good advice. Sadly, it has a dark side.

"You can be healthy!" shout the covers of magazines and health books. The promise is that all it takes for good health is good exercise, good diet, and good hygiene.

But what does it mean if we aren't like those good people on the covers of health magazines? What if we aren't slim or young or fit? What if we're at risk of illness -- or actually ill?

We all have an ideal self we feel we should live up to, says psychologist Lawrence Josephs, PhD, a professor at Adelphi University. And we feel ashamed when we don't live up to this ideal.

"Everybody believes they should be healthy and fit and youthful and live to a ripe old age," Josephs tells WebMD. "But people do get weak and vulnerable and depend on others and need help. So that ideal of being a strong, healthy person who can do everything on their own, that is shattered. And people get shamed and don't want to admit they are ill."

Shame: A Major Health Issue

In the experience of shame, one's whole being seems diminished or lessened. The expression of shame is not just the desire to hide, or to hide my face, but the desire to disappear, not to be there. It is not even the wish, as people say, to sink through the floor, but rather the wish that the space occupied by me should be instantaneously empty. -- Bernard Williams, British philosopher

The effects of shame and stigma can be devastating to a person's health, experts tell WebMD. They're seen not only in people with life-altering medical problems but also in relatively healthy people with risk factors (such as a family history of cancer) for future illness.

Examples include:

  • AIDS patients not taking their lifesaving drugs.
  • People with diabetes becoming discouraged over difficulties with blood-sugar control.
  • Obese people ashamed to go out of doors and get the exercise they desperately need.
  • People with urinary incontinence afraid to leave their homes.
  • Unnecessary suffering in people with treatable mental illnesses.

Duke University researcher Laura Smart Richman, PhD, studies emotional influences on health.

"Shame is one reason why people don't seek care," Richman tells WebMD. "There tends to be this perspective that people should have a lot of control over their health -- even with an illness like cancer. We're told, 'You should think positive, you should eat the right foods.' So when people aren't healthy there is self-blame and the perception of societal blame."

Taking personal responsibility for one's life is a good thing. We all want to be independent and in control of our lives. But illness isn't something we fully control. That can be scary -- and shaming.

"People want to think, 'I am in control,' so if you have alcoholism, addiction, eating disorders, incontinence, whatever, there is shame in lack of self-control," Josephs says. "Shame can be dangerous if it keeps you from seeking help for anything serious. It is very upsetting to have a heart attack scare or a cancer scare. It is tempting to deny it -- because that is a big assault on our self-image."

This isn't merely a matter of vanity, or even of being a control freak. Shame is hardwired into our mental makeup, says psychiatrist Michelle E. Friedman, MD, director of pastoral counseling at Yeshivat Chovevei Torah rabbinical seminary and assistant clinical professor at Mount Sinai School of Medicine, New York.

"This is an issue and a struggle for every ill person," Friedman tells WebMD. "Shame comes from an ancient, primitive way of thinking. It is really powerful."

We feel guilty for what we do. We feel shame for what we are. A person feels guilt because he did something wrong. A person feels shame because he is something wrong. We may feel guilty because we lied to our mother. We may feel shame because we are not the person our mother wanted us to be. -- Lewis B. Smedes, U.S. psychologist

Why is shame such a problem? It has to do with the nature of this mixed emotion. Like its sister emotion, guilt, shame is what psychologists call a negative emotion.

Negative emotions such as sadness, anger, and fear -- alone or in any of their many combinations -- aren't bad in and of themselves. It's how we handle them that makes them harmful. In this regard, shame is particularly tricky. It strikes at the core of our being, says psychologist June Tangney, PhD, a professor at George Mason University in Fairfax, Va. Tangney is co-author of the book Shame and Guilt.

When we feel bad about having failed or about having done something we think is wrong, we feel guilt or shame.

"Guilty people feel bad about their behavior. Shamed people feel bad about themselves," Tangney tells WebMD. "Guilt is a less overwhelming feeling. It is less self-esteem related, and doesn't affect our sense of who we are."

Guilt motivates a person to repair the damage done by bad behavior and to make positive changes in their lives. Shame works in the other direction. It makes us want to disappear.

"When people are ashamed, the defense mechanism is hiding," Joseph says. "We become like little kids who are ashamed and hide their faces in their mothers' aprons. It is hard to get past that."

As adults, we don't have our mothers' skirts to hide behind. But our reaction to shame often isn't any more mature.

"When people feel ashamed they are more likely to hide, deny, escape, and externalize blame," Tangney says. "When people feel guilt they are motivated to face the music. When people feel shame they want to duck the heat."

Tangney lists five ways shame can be destructive:

  • Lack of motivation to seek care.
  • Lack of empathy. Shame, Tangney says, is very self-involved. People feeling shame cut themselves off from other people.
  • Anger and aggression. Tangney says shame has a special link to anger. "In day-to-day life, when people are shamed and angry they tend to be motivated to get back at a person and get revenge," she says.
  • Psychological problems. Tangney says shame is associated with eating disorders, substance abuse, anxiety, depression, and other mental disorders.
  • Problematic moral behavior. Tangney's team tested fifth-grade students, and followed them until they were 18 years old. Shame-prone kids were prone to substance abuse, earlier sexual activity, less safe sexual activity, and involvement with the criminal justice system.


Negative emotions are more powerful than positive emotions. See Answer

Because we tend to feel more shame about our bodies than about other aspects of ourselves, health issues are particularly likely to evoke shame. And no health issues evoke shame more than those involving sex, says Ilan Meyer, PhD, associate professor of clinical sociomedical sciences at Columbia University's Mailman School of Public Health.

"If people are embarrassed to talk about their sexuality, they are not going to be seeking out services, testing or counseling on the topic," Meyer tells WebMD. "People often don't seek treatment for an STD [sexually transmitted disease]. Or when they do, they lie or pretend it is something else. I know of someone with an STD who called the doctor and said he had a cold, and wanted antibiotics. Of course this would be the wrong drug for both conditions, but this is a case of a person acting out of shame, trying to manipulate the situation to get care."

In the Bible, God often punishes people by making them ill -- often with humiliating diseases.

"That is very much lodged in people's minds," Friedman says. "When something goes wrong with our health we think, 'What did I do to deserve this?' People feel -- and this may be an unconscious feeling -- that if something befalls them, they somehow did wrong."

It's a pernicious feeling. If we feel bad because we are sick, we can be treated for the sickness and feel better. But if we feel sick because we are bad, we are powerless.

Religion isn't the problem here. If we feel that our fate is in God's hands, we aren't afraid to seek treatment. We become powerless only when we believe our illness stems from a moral flaw that we must hide from everyone, including God.

What do you regard as most humane? To spare someone shame. -- Friedrich Nietzsche, German philosopher

One of the oldest stories of healing shame is in the Old Testament, Friedman notes. God punishes Miriam by giving her leprosy. He answers Moses' prayer that she be healed, but insists that she must be shamed by being expelled from the Israelites' camp for seven days.

Even though they are in dire circumstances -- they are escaping Egypt for the Promised Land -- the Israelites do not move from camp until Miriam has served her sentence. Then they welcome her back from her shame.

"Miriam had to be marginalized so that her shame could be recognized. But then the whole camp waits for her to welcome her back from her shame," Friedman says. "But if you are marginalized, who is inviting you to dinner? If you are someone who has fallen through the cracks, who is thinking of you? A fact of modern cultural life is that there is a decreased attention to integrating marginal people into some kinds of communities."

One relatively recent positive change is that more and more celebrities are speaking out about their own shame-associated conditions.

"When celebrities come out with their stories -- like Brooke Shields talking about her postpartum depression -- that is a very big thing," Tangney says.

But often, simple human contact is the most important thing for a shamed person. Even this can be difficult to offer because shame makes people withdraw.

"The most important thing is to keep up contact with someone -- for example, the kid who drops out of college and is now a strung-out marijuana addict," Tangney says. "Marginalized people -- and nobody is more marginalized than the mentally ill -- need to have a place in society. That is a very powerful message that should be attended to by communities, whether they are religious or family or neighborhood communities."

Approaching a shamed person can be tricky, Josephs warns.

"If you see shame preventing someone from getting health care, you can confront it as irrational," he says. "You can say there is nothing to be ashamed of, and if people hear it, they hear it. But when you point out that they are ashamed, people can get touchy and angry. If you point out their shame, you could get into a fight. So bring it up, but in a tactful way, knowing this is a tough issue."

Tangney says that the best approach is to avoid further shaming. The first thing to offer is support and empathy. Rather than confront a person's shame, it's better to point out -- very, very gently -- how a person's behavior is harming areas of life that the person really values.

"There is a lot of evidence suggesting this is a good approach," Tangney says. "And to my ears it is all about shame reduction."

Published May 9, 2005.

SOURCES: Michelle E. Friedman, MD, private practice psychiatry; director of pastoral counseling, Yeshivat Chovevei Torah rabbinical seminary; assistant clinical professor, Mount Sinai School of Medicine, New York. Lawrence Josephs, PhD, professor of psychology, Derner Institute, Adelphi University, Garden City, N.Y. Ilan Meyer, PhD, associate professor of clinical sociomedical sciences , Mailman School of Public Health, Columbia University. Laura Smart Richman, PhD, assistant research professor, Duke University. June Tangney, PhD, professor of psychology, George Mason University, Fairfax, Va. The Columbia World of Quotations, Tangney, J.P. and Dearing, R.L., Shame and Guilt, Guilford Press, 2002.

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